getting you back to baseline

Can it be...MTD? Muscle Tension Dysphonia Defined.

Completely over diagnosed. Wrongly diagnosed. Underdiagnosed. What the heck is MTD?

Muscle Tension Dysphonia is a term that describes a certain type of voice problem or voice disruption with massive underlying tension, and no other pathological cause. So you have an odd vocal quality or hoarseness, and you are as wound up as Lindsay Lohan's newest attorney. This tension can be found in the upper body area, like the shoulders, neck, jaw, base of tongue and the larynx. The tension can be painful, and many times there are concomitant conditions like stress and emotional conflict making the symptoms worse. There are 2 types of muscle tension dysphonia according to Clinical Voice Pathology by Stemple et al, and 3 according to the voice doctor, Dr. James Thomas.

Do you see cases of MTD in your practice? MTD can often be confused with Spasmodic Dysphonia, so it is important to correctly identify each. I see a lot of vocal hyperfunction, and it's a mix on the cause. Most of the time it is easy to see that there is overcompensation for lack of true vocal fold mass, movement, etc. You must make sure you are taking into consideration the type of examination when making a diagnosis. No one likes a rigid scope in the mouth, so some laryngeal tension could be caused from the exam itself.

Three Types of MTD:

Primary MTD (Non-organic hyperfunction)

Primary MTD (muscle tension gap)

Secondary MTD (hyperfunction in presence of vocal disturbance)

Stemple and colleagues describe Primary MTD as excessive tension affecting the voice with no other cause. Dr. Thomas agrees, and elaborates on two different types of Primary MTD. He divides the primary category into two: Non organic dysphonia/hyperfunction and muscle tension gap. Primary MTD can present as hyperfunction on a videostroboscopy examination with complete closure of the true vocal folds, however there is some type of superior constriction present. That means that you will see anterior-posterior or medial compression above the true vocal folds. The false vocal folds may be squeezing together so tightly that your view of the true folds is almost completely obscured. This might make it hard to see if there is underlying weakness. This type of patient may have developed this excessive hyperfunction gradually and now it has become the new normal for making sound. Voice therapy can ease the tension with upper body relaxation stretches, circumlaryngeal massage and tension-free phonation training.

Muscle tension gap is different, Thomas argues. He states that the vocal folds can remain open secondary to abductor and adductor muscles simultaneously contracting during phonation. Like the non-organic MTD, this can be learned and compensatory. It could be a muscular habit that will not die, like if vocal nodules are removed. Vocal nodules can be improved and eradicated usually by voice therapy alone, but some surgeons still operate. The patient has learned the way to make sound with the nodules present, a little like playing football with a poorly inflated football. (You can do it successfully after a learning curve, but it's probably going to cause some trouble. Sorry Tom Brady.) An hourglass vocal fold closure is all that can be achieved. The adductor muscles only have to bring the vocal folds together to a certain degree before the nodules prohibit any further contact with the remaining free edges of the folds. Fast forward to the nodules being suddenly removed by a surgeon, the muscles may maintain that same pattern, and only come together so closely. Voice therapy can teach the patient how to phonate completely (and achieve that full closure again) by teaching new motor patterns.

Secondary MTD involves a pathology of some kind like paralysis or lesions, where the patient is overcompensating for the deficit. Secondary MTD is dubbed hyperfunction representing hypofunction by Thomas. With a pathology present, the patient is utilizing hyperfunction to compensate for lack of true vocal fold use. You need to look beyond the superior constriction here to notice why the patient is squeezing. Is there a paralyzed vocal fold? Is there bilateral atrophy and bowing? Is there a polyp? Is there recurrent laryngeal nerve damage? Voice therapy can be beneficial here, but it would be best to address the underlying issue first. If it is atrophy, the patient's ENT might consider implants or injectables. If it is paralysis, the ENT might recommend waiting about 9 months to see if it is true paralysis before laryngoplasty.

Dr. Thomas has this nice educational video to aid in any persisting confusion.

So when you see a patient with laryngeal hyperfunction, make sure you are determining what is causing the hyperfunction. If you're coming up empty handed (not to be confused with a deflated football in hand), perhaps it is true MTD.

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Charting at the time of patient care is vital to my ability to provide quality services. If I wait too long, my notes aren’t as detailed and I forget to notate everything I did in a session with a patient. I refer to each previous session to know how to proceed and I like referring to my goals for each patient EVERY SESSION so I make sure I’m on the right track. Electronic charting has truly changed my life. I type relatively quickly and like that I can pre-populate phrases I use often, and can customize. .
.
. 👚: @dickiesuniforms . 💇🏼‍♀️: @britanymarshallbeauty
#slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

Where do I begin? Of the 30 years you’ve been in this earth, I’ve been lucky to be present for the last 12 of them. I can’t even count all the memories and I tried my best to collect some of them in pictures from the span of time I’ve called you friend. Crazy times, beautiful times, sad times and hard times. I love you @bionda_saraphine. You are my person. Happiest of birthdays to you. We were lucky to celebrate with you last night.

When you get off work early and you’re still in your #DickiesMedical scrubs, you get on your knees in the onion patch with the original Dickies wearer in the family! I mean, the man has been wearing these jumpsuits since I can remember. He may be 99, but he still stays as active as ever. Remember all my website photos of the gray haired man looking at his #vocalfolds? That’s the legend! How did you spend your afternoon?
.
.
.
.
#brandambassador #ad #slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

Been wondering about what is best practice for voice evaluations? What is the bare minimum you can scoot by with? Check out @speech_science’s podcast featuring Kristie Knickerbocker from A TEMPO Voice Center talking what is most important and what's the deal with videostroboscopy! bit.ly/Episode26Voice
.
.
.
#slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

When your voice colleagues @dr.bernard.rousseau & @branskir come to town for an @aahconsulting presentation, you do what any normal person would do....you meet at your #crossfit box @crossfitpanthercity! Sorry it wasn’t an amrap to get us moving, but you guys knocked out some pretty impressive strict hand stand pushups 😉 If you haven’t checked out the great things they’re doing with speechandhearingprofessionals.com, you should sneak a peek 👀 .
.
.
#slp #slpeeps #instaslp #ashaigers #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #medslp #snfslp #snfspeech #womeninmedicine #voicerehab #atempovoicecenter #aahconsulting #referralnetwork #healthcare

The beautiful @stacypepp popped in today for the most generous gift of SATB sheet music from her church in Pampa. It’s like glorious boxes of this stuff! 😍 I will be needing this for something big coming soon, and it couldn’t have come at a better time. Thank you so much Stacy, my 💜 is full! #gofrogs .
.
.
.
#slp #slpeeps #instaslp #ashaigers #choralmusic #choir #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

Serendipity: A chance encounter. So, a few days ago, I made an online sale of my #confidentclinician video to an SLP from my hometown. I will admit to Facebook stalking her because it seemed coincidental that she was from #bearcat country. Fast forward to this evening, when after a busy clinic day, the fam and I made it to @presscafefwtx for some dinner. And who should be there also? Wearing black #scrubs? 👯‍♀️@mc_richter that’s who! What a small 🌎! And here’s to many more chance encounters! .
.
.
.
#slp #slpeeps #instaslp #ashaigers #scrubs #womeninscrubs #slpa #medical #speechpathology #speechies #slpsfollowslps #speechtherapy #speechtherapist #slp2b # slplife #scrubslife #medslp #snfslp #snfspeech #womeninmedicine #vocologie #thisisvocology #voicetherapy #voicerehab #atempovoicecenter

How often should you be hydrating?

Get in the habit of drinking half of your body weight in ounces of water each day. I label my water bottles with times I must drink a certain amount by. Get a nifty looking reusable bottle to help keep you motivated.

Cough Drops?

Try Breezers by Halls. They do not contain menthol or eucalyptus. Those ingredients can contribute to chronic cough.

Vocal Abuse Tip

Instead of yelling from room to room at home, bring the communication partner closer to you when communicating.

Connect with us

No portion of this website is intended to diagnose or treat any medical problem. It is meant to help further understanding of voice and swallow related issues. Please make an appointment with a licensed Speech Language Pathologist or Physician for assessment.